Medicaid managed care organizations and other health insurers, as well as fee for service (FFS) Medicaid programs, sometimes require pre-approval before an enrollee can obtain a treatment, prescription, equipment, or other covered service. While prior authorization is often couched as a way to make sure the service is medically necessary, safe, and cost-effective, it can create substantial barriers to care. Working at both the state and federal levels, NHeLP’s Delivery Systems Practice Area works to increase accountability and transparency to prior authorization of services and wrongful service denials. We seek better reporting of when prior authorizations are applied and how frequently plans deny requested services. We push for active oversight measures, such as independent medical reviews, to ensure the criteria used to make coverage decisions are clinically appropriate and nondiscriminatory, including when plans use automated decision making and artificial intelligence (AI) tools for these decisions. Overall, we aim to rein in the overuse of prior authorization, reduce the administrative burden on providers and enrollees seeking needed care, and make it easier for enrollees and providers to contest wrongful denials.
